The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Tag Archives: video games

I am convinced that you can’t fight culture. Whereas we in the US have multiple subcultures, there is a general culture that values multi-tasking, technology use, and lack of downtime. The consequence seems to be a relative lack of tolerance for ambiguity and spontaneity, both of which are often associated with creativity. That is not to say that there are not creative individuals in our society nor that there is no creative activity, but it seems to me likely that one has to step out of the typical mind set and pattern of activity of contemporary American life to be truly creative. I accept the misconceptions that underlie idealization and the romanticization of other cultures, particularly those of developing cultures closer to their ethnic roots. However, I cannot be blind to the advantages I see here at the orphanage and school in South India and in the orphanage in El Salvador where I am a regular guest.

Two apparent advantages are – at least in the case of the younger children – plenty of down time, and few toys, especially tech toys. In the evening last night, the gentleness of the temperature matched the tempo of the activity of the courtyard of the boys’ residence. Boys of different ages were playing in two main groups. One group was playing with a volleyball. Two older boys, one of whom had just graduated college, were playing ball together with obvious enjoyment. About 6 much younger boys were trying to capture the ball, while also imitating the older boys’ athletic moves. Sometimes the older boys would allow them to take the ball, and there would be a playful skirmish between the younger and older boys that looked more like a soccer game than the original volleyball. Other times, the older boys continued to play together without much attention to their younger followers, who watched them closely, while also running around. How much learning was going on in that admiring observation, and how much healthy physical activity and enjoyment! There was no conflict among the boys that I could see.

The other group of boys was playing with stiff slender stems of a plant that they used as arrows. They fixed a small rubber band to the rough end of the stick and pulled it with their fingers while pointing the stick upwards. When they released the rubber band, the stick soared into the air. After a while they identified a tantalizing target – a huge jackfruit hanging low on a tree. As the arrows hit the target again and again a milky substance started to seep mysteriously from the fruit. Here also, there was no real conflict. No adults were constraining their activity, telling them what to do or what not to do. No one cared that the fruit of the tree was being injured – it wasn’t as if a precious garden tree or a piece of furniture in the family home was being harmed. The children were free to play unencumbered. How many of the limits we place on children are dictated by the environment in which we expect them to play?

The comfort of the boys in the courtyard was mirrored by the children in the kindergarten classroom. Thirty two children were sitting on small mats on the floor, overseen by one teacher. The teacher, a superb teacher I had known from earlier visits, was calling on the children one at a time to come to the front and create a story out of a picture with four panels of images. This is a rather sophisticated task, requiring them to create a coherent narrative out of the pictures, and the children were doing a good job. At least as impressive was the attentiveness of the other children while the narrating child was at work. Every once in a while one child would start to cause a minor disruption. The teacher did not call the child’s name from a distance. Without speaking at all at first, she moved to his or her side and put her hands gently on their shoulders, moving them back into position. Is there any way we can transport this into our culture?

Jerry is a 13-year old boy who will not get off the computer. His mother in particular gets into terrible struggles with him when it is time to do his homework and he is intensely involved in a computer game that he refuses to leave. If it were not for his homework, his mother would not object as much, since he is developing skills in fine motor coordination, pattern analysis, and quick reaction time – to say nothing of his facility with computers! – And also he often engages in interactive games with his friends, which are collaborative as well as competitive and highly social. The main problem is that he does not do his homework. As soon as he comes home from school, he rushes to his computer and begins a game. When it is time for homework, supper, or bed, he refuses to get offline. (In response to a NY Times column about the subject, I found interesting comments from parents.)

It is not that Jerry does not care about school. He is very ambitious and conscious of the success of his slightly older sister, with whom he is highly competitive. He is discouraged about his school record and dreads receiving his report card, but he seems unable to accept help. When his teachers offer him extra help, he usually politely thanks them but does not show up for the scheduled session. He refuses any regular tutoring assistance. Last year he would ask his mother or father to sit in the room with him while he did his homework – although he would not allow them to help him in any concrete way – but this year he refuses any support from them. This drives them wild with feelings of worry and helplessness.

Jerry has always been an active, rather disorganized child, interested in sports and fairly good at them, but intense and prone to tantrums. He has such a short fuse that his parents and sister have tended to monitor his moods closely and when he is in “a bad mood”, “walk on eggshells” to avoid an outburst. His parents have extended themselves in many ways to try to make things better for him. They have helped him play the sports he choses and attended all of his games. They have advocated for him fiercely at school. Still, family life has been hard.

His mother says that when he is on the computer he is happy and excited, and completely involved. When he gets off the computer, he falls apart – becomes irritable, disorganized, infantile, and sometimes aggressive. When he acts like this, she tries to negotiate with him, but his negative behavior just escalates until a blowup. After that, when she tries to talk to him about what just happens, he either blows up again, or he leaves and slams the door behind him. His father sometimes has more luck with soothing him when he is irritable, but he is not much better at getting him to leave the computer or do his homework. His mother feels that she is always “the heavy” and expected to set limits and keep order in the home, while her husband comes and goes when it serves him. Sometimes she thinks that if he were “more present” as a father, Jerry would not be in trouble – and when she is at her wits’ end, she will tell him so – but other times she acknowledges that there is no simple answer for Jerry’s difficulties.

Both Jerry’s parents came from modest backgrounds and were exceptionally high achievers as children and adolescents. They now both have successful professional careers, though perhaps not at the level or degree of satisfaction that they had envisioned. Whereas his father had studied at Julliard and had imagined a career as a performing musician, he now teaches at a private school and works at composing music in his spare time. His mother, who had won national prizes as a figure skater, is now a coach.

This story is an elaboration of the “transition to school” posting, since it also involves homework. There is an excellent set of posts on the Child Mind Institute on transition to school that can be helpful to caregivers. They include good strategies to try first. A colleague has written a thoughtful blog post about the transition to kindergarten. Many of the children whose parents consult me have tried or could try these strategies without success. The story of Jerry is an example of such a case. My posting is to remind caregivers that each child is unique and has an inner world of his own, so that general strategies – no matter how intelligent or thoughtful – are sometimes not the answer. Rather, trying to imagine what is going on inside the child’s mind is the best way to start every effort to scaffold a difficult transition. Let me know what you imagine about what is in Jerry’s mind.

Just before I left on vacation, a mother of a child in my practice asked me why it was so hard for her 6-yo son to make transitions. I was rushing to get ready to leave, so I sent her a quick email promising to respond more fully when I had a chance to think about it. I have had her question in the back of my mind and was especially struck by it when I arrived in Europe and experienced jet lag. It occurred to me that jet lag was a good metaphor for the kind of transition the mother was asking about.

First of all, her child is one of those highly sensitive children I refer to as “race horses”, of others in the literature have called “orchids”. He is extremely intelligent but sometimes retreats to infantile behavior patterns, and he often reacts with extreme distress in the context of transitions – even simple daily transitions such as getting up and getting ready for school in the morning or leaving play to go somewhere or do something else. This problem is interesting because it gets mixed up with all sorts of other categories of problems – such as problems with compliance (behavior problems) or sensory over-responsivity problems (SOR) (Ben-Sasson et al, 2010).

I think there are reasons for this confusion.As writers on “orchid” children point out, it is easier for children with certain temperamental characteristics to readjust to changes in their environment. (I chose the above photo of young Indian dancers because I imagined – though I do not know these children – that the girl on the left has an easier temperament than the girl on the right.) These delicate children are often much harder to parent than children with easier or more resilient temperaments (“dandelions”), and parents and child often initiate problematic interaction patterns early on that can influence the child’s developmental trajectory in an unfortunate direction. It then becomes the job of the child therapist to help the family (child and parents) correct this misdirection.

The kinds of problematic patterns that are characteristic of this situation typically involve mutual over-control. That is, children who feel highly stressed by demands for change (in other words, transitions) often try to exert a counterbalancing force by controlling their environment (their parents, included). Parents may respond either by engaging in a control struggle with the controlling child or by giving in, or by both (Granic, 2006). When these patterns are repeated, they become more firmly rooted in family behavior. I refer to this as building stronger infrastructure for the problem cities (metaphor for problematic relational patterns such as struggles in families) so that it is easier to get there and stay there. Of course, it is better for all involved to build strong infrastructure for the cities that represent more adaptive behavior patterns such as collaboration, but when people are stressed, they often choose the behavior that takes less energy (from the point of view of managing emotions and using reflective capacity) in the short run and more energy in the long run (having to repair the ruptures that struggles and fights cause in the family).

The job for child therapists is to work with child and family to “break the habits” of the problem behaviors and substitute more adaptive patterns. This is done by a variety of techniques including gaining insight into the meanings underlying the behavioral reactions of child and parents and supporting the emotional regulation of all concerned, and then … practicing the new more adaptive patterns again and again and again. I will write more about this important aspect of the topic in a future posting, but I will limit myself here to the mother’s question of “why?”

Let me return to the metaphor of jet lag. My intention is not only to respond to “why” a child has trouble with transitions, but also to offer a way of empathizing with the irritable child. (Often, a parent empathizing with the child allows her or him to better imagine the child’s mind and this can facilitate the parent’s choice of response to the child’s demanding or oppositional behavior). I found a good article on jet lag that describes it in terms of whole organism dysregulation (Vosko et al, 2010). Circadian rhythm – sleeping longer at night and less during the day – is one of the first organizations to emerge in the developing newborn (Sander, 2008). It is achieved through a series of oscillatory networks that include a master oscillatory network in the suprachiasmatic nucleus (SCN) in the brain and also sensitivity to environmental light cues (Vosko, p. 187). During jet lag, the paper continues, abrupt changes in the environmental light-dark cycle desynchronize the SCN from downstream oscillatory networks from each other, disrupting sleep and wakefulness and disturbing function (ibid, 187). This kind of “circadian misalignment” can lead to a series of symptoms, including major metabolic, cardiovascular, psychiatric, and neurological impairments (ibid, 187). During this trip, as usual, my jet lag “took over”. Although I intended to stay awake and enjoy the company of my friends and the new landscape, I was compromised in my ability to do so. The feeling of dysphoria came in waves; sometimes I felt my old self again and other times I felt tired, irritable, and even sick.

The benefit of this metaphor is that it emphasizes the notion of whole human being “organization”. Many problematic behaviors result from a disorganization of adaptive patterns of functioning. The human organism is constantly working to keep itself on track and to accommodate small bumps and disruptions. It is when the reorganization does not happen smoothly, when things fall apart, that a “symptom” appears. The symptom can be physiologic as well as emotional, just as in jet lag. Children who have delicate temperaments or other developmental reasons for high sensitivity (such as children with ASD, uneven development, trauma, or SOR) are particularly vulnerable to this problematic disorganization.

Consider all the demands for reorganization that a child has to respond to on a daily basis: She has to wake up, changing from a sleep state to an alert state. She has to get up and get ready for school, requiring many transitions from the multiple small tasks involved in washing and dressing. She has to eat breakfast, even if she is not hungry at the time. She has to say goodbye to home and parents and make a big shift from a relatively dependent position to a more autonomous position in terms of initiative and compliance. When she gets home from school she has to deal with other important transitions. Don’t think for a moment that greeting a beloved parent is necessarily going to be a pleasant experience; the transition from a holding-it-together-at a higher-level-of-organization-state at school to a more relaxed and dependent one at home is often bumpy! In addition, often parents of sensitive children give them aids to help them keep organized in the transition, such as video games. As I have mentioned in another posting, these games work very well to keep a child organized because they provide an effective external regulator. When this external source of regulation is taken away abruptly, it can be expected to cause great distress. Even a book, a much more adaptive regulating activity, can cause distress when discontinued.

What is the answer to these problems? I will respond in a subsequent posting!

Recently, a child in my practice has become a minecraft afficianado. This child is very smart but has processing problems and struggles in school. He is adept at the game, which wins him admiration from his siblings and peers, with whom he plays the game both at home and in free periods at school. When he brought the game in to show me, on his mother’s iphone, I was impressed by his proficiency and also noted the fact that he talked to me more – about the game – and in a more coherent fashion, than I can remember his having done before. I was pleased. However, I was also suspicious, because I have had a rather negative view of videogames and their effect on my child patients for quite a while. Was this game going to change my mind?

I had always thought that videogames were attractive to children with regulatory problems – for example, kids with learning disabilities, processing problems, or tricky moods – because in playing the game the child experiences strong affect and intense physiological arousal that is highly pleasurable and that is otherwise unavailable to the child without the negative consequence of his falling apart. That is because the game is doing the regulating for him and the child is the passive recipient of the structure and rhythm provided from outside.

The problem with this is twofold. First, the child needs all the practice in self-regulation he can get, and he isn’t getting any playing the game. Second, it is very unpleasant to discontinue this experience – a real downer, and that leads to a set of other problems. Children with regulatory problems often have particularly difficult times with transitions, and a parent’s demand that the child leave such an attractive activity can often generate a struggle or provoke a fight. In addition, parents of these children typically have a hard time setting limits on their children’s behavior due in large part to the child’s neuro-cognitive challenges, and old struggle patterns can be triggered by these demands for compliance, in effect “practicing” these problem patterns and making them worse.

Then by coincidence, a colleague, Dr. Tim Davis, brought up the game of minecraft in a clinical discussion we were having about another child. Tim supported my original opinion of the game. Tim said that the game presents the player with small tasks and an immediate reward, in that way offering gratification to the player who has organizational or processing problems. This may contribute to a tendency for children to prefer this game and avoid more difficult but more growth enhancing activities, or for these reasons may even lead to an addictive behavior. Yet, Tim and I are of the same opinion about setting limits on videogames like this. We both think that it is better not to prohibit the game completely, especially since the game is often popular with the child’s peer group, and these children often need all the support they can get “fitting in”. However, this puts a large strain on parents, because it means that you are setting limits all the time on a child who responds poorly to limit setting. On the other hand, it gives parents and children the chance to practice very challenging negotiations so that they can build their competencies. Each family has to set their own rules, but generally I recommend that children not play videogames until their homework is done and done well (not dashed through to get to the game). On weekends, parents may also wish to insist on another kind of play with peers or physical exercise before the videogames. The time children are allowed to play videogames – or the time allowed for any “screen time” varies from family to family.

Later, I contacted another colleague who knows a lot about videogames, Dr. Peter Chubinsky. He wrote me back, “After a break from serious gamers in my practice, I find myself doing psychotherapy with some older adolescents with great passion and skills for these video games. They now realize as their parents had years before that being the greatest wizard on a 200,000 person server, or having the most kills and earning the respect of soldiers playing online with you are not the best answer to the question on their college application, ‘What accomplishment in high school are you most proud of?’ Even more compelling to my patients and the motivation to modify their gaming is realizing how poorly the games have prepared them for finding a girlfriend!”

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.